- Email: [email protected]
P104
Abstracts: 2007 Poster Session / Surgery for Obesity and Related Diseases 3 (2007) 299 –344
active H.pylori infection. The HpSA test represents a sensitive, noninvasive means of surveillance for active infection and response to treatment that is well suited for gastric bypass patients. PII: S1550-7289(07)00342-5 P101.
INSURANCE COVERAGE FOR BARIATRIC SURGERY: WHO GETS DENIED AND WHY? Vijaya L Nirujogi, MD; Ballem Naveen, MD; Silas Chikunguwo, MD; Bipan Chand, MD; Philip Schauer, MD Cleveland Clinic, Cleveland, OH Background: The aim of this study is to illustrate the frequency and reasons for insurance denials and ultimately aid the patient and physician navigate through the appeal process . Methods: This is a retrospective analysis of all patients evaluated at our institution for weight loss surgery from January 2005 to June 2006 that met the NIH criteria for surgery. All patients were evaluated by the bariatric team and fulfilled the criteria for surgery. Data was collected for variables including age, sex, BMI, comorbidities, Insurance carrier and the reason for denial. Results: Results: 615 patients who met the criteria for weight loss surgery were submitted for pre approval and 120 were denied (19.5%).Of these 94(78.3%) were women, 26(21.7%) were men, mean age was 44yrs, mean BMI⫽51 (range⫽35-89) kg/m2, mean number of. comorbidities ⫽ 3 (range⫽0-9). There were 2 deaths among the 120 patients waiting the appeal process, a mortality rate of 1.7%. Twenty one (17.5%) patients appealed the denials and of these 12( 57%) were ultimately approved . Conclusion: We found that the insurance companies cited lack of adequate documentation of supervised diet as the primary cause of denial. Contrary to this we noted extensive documentation to multiple failed diets. There were 2 deaths among the 120 patients waiting the appeal process, a mortality rate of 1.7%, almost double the national average of mortality rate for Roux-En-Y gastric bypass. Almost 20% of the eligible patients were denied access to surgery for reasons that have no proven benefit on patient selection or the outcome of surgery. PII: S1550-7289(07)00344-9 P102.
BARIATRIC SURGERY. . .WHY NOT? Joanne Rogers, CNS; Stephanie F Yeager, RD; Diane Daddario, RN; Christina Hartman; John Gerdes, PhD; Peter N Benotti, MD, FACS; Anthony Petrick, MD, FACS; William E Strodel, III, MD, FACS; Christopher D Still, DO, FACN Geisinger Medical Center, Danville, PA Background: Many qualified patients interested in bariatric surgery will not complete requirements needed to have surgery or ultimately decide not to have surgery. Current literature points to psychiatric issues, especially depression, as the major reason for drop-out in these types of programs. With the health risk of staying at a morbid obese state usually higher than those risks of surgery, we investigated reasons why patients who started our 6 month pre-surgical education program did not have their surgeries 1 year after starting. Methods: Twenty-eight patients of 61 total new patients were placed in the pre-surgery program, 3 of these patients had surgery within 1
333
year of the initial visit. The remaining 25 patients (18 females; 7 males) were interviewed by telephone. The question asked was “What factors contributed to why you initiated a program for bariatric surgery but did not continue treatment?” Total responses were collected; a respondent could have multiple answers. Results: Summary of responses: insurance issues-8 (32%); concern of surgical risk-6 (24%); fear of lifetime change-4 (16%); other medical conditions-3; life issues-3; reason unknown-3; distance-2 (8%); depression-2; unable to pay the program fee 1; work-1; prison-1; felt lost in the system-1; surgery elseware-1. Conclusion: These results suggest that insurance issues, concerns of surgical risk and fear of lifetime change are major barriers for patients undergoing bariatric surgery in our population and not psychiatric illness or depression as the current literature suggests. We may need to change the method of education to increase completion of the program. PII: S1550-7289(07)00345-0 P103.
THE ACCURACY OF SELF REPORTED WEIGHT AND HEIGHT IN THE BARIATRIC SURGERY PATIENT. Lauren Guenther, RD; Linda Bailoey, PA-C; Coleen Curley, RD; Ramsey M Dallal, MD, FACS Albert Einstein Heathcare Network, Philadelphia, PA Background: BMI is a critical value in the evaluation of patients for bariatric surgery. We examined the accuracy of patient reported height and weight in patients presenting for bariatric surgery. Methods: Patient weight and height were measured in our office and compared to weight and height that was self-reported on pre-registration materials. Results: 110 patients that were candidates for bariatric surgery were examined. Thirty-seven people (36%) were incorrect by an inch or more. Patients were equally likely to underestimate as overestimate their height. Average deviation from measured height was 0.03⫾0.96 inches. Patients either under- or overestimated their weight by an average of 2.2⫾2.4%. Fifty-eight patients (53%) deviated more than five pounds from their actual weight. Increasing weight predicted increased inaccuracy of self reported weight as a percentage of actual weight. Those patients ⬍ 300 pounds were inaccurate by 1.6⫾0.01%, those patients ⬎ 300 pounds were inaccurate by 3.1⫾0.3%, p⬍0.05. Patients were 1.7 times as likely to underestimate their weight than overestimate it. On average, reported and actual BMI were not statistically different. In four patients (3.6%) the BMI was affected by more than 5 points. BMI was accurate to 0.045⫾2.5 points comparing actual and reported values. Conclusion: Patients under-evaluation for bariatric surgery were surprisingly accurate with reporting their weight and height. Deviations in reported and actual BMI were clinically insignificant. PII: S1550-7289(07)00346-2 P104.
SUICIDE RISK IN LAGB PATIENTS. Eric H Prensky, PhD; Margaret Primeau, PhD; Mara Stankiewicz; Vafa Shayani, MD Loyola University Medical Center, Maywood, IL Background: Depression is common among morbidly obese patients according to both epidemiologic studies and the bariatric
334
Abstracts: 2007 Poster Session / Surgery for Obesity and Related Diseases 3 (2007) 299 –344
surgical literature. This comorbidity is not simple, though: symptoms of depression may improve, fail to change, or actually worsen following successful weight-loss surgery (e.g., Ryden et al., 1989; Waters et al., 1991; Dixon et al., 2003). We were prompted to investigate the prevalence of depression and suicidal ideation among our bariatric surgical patients when one was emergently admitted for intentional medication overdose 23 months after laparoscopic adjustable gastric banding (LAGB). Prior to surgery, this patient had denied acute depression. At 23 months, the patient had lost 51% of excess weight (%EWL). Methods: Preoperative data from psychological evaluations of 92 consecutive LAGB patients were tabulated. Frequencies represent patient responses to standard interview probes. Partial correlations were calculated for preoperative depression scores (MMPI-D)and later %EWL in 62 patients with at least six months follow-up. Results: A history of depression (53%) and current depression (28.4%) were common preoperatively. In addition, 14% acknowledged past suicidal ideation, and 3.5% reported a past suicide attempt. One patient disclosed current suicidal ideation, and 14% indicated a family history of a suicide attempt. Eventual weight loss was negatively but modestly correlated with elevations in preoperative depression (r⫽-.28, p⬍ .05). Conclusion: While histories of depression and suicidal ideation are far more common in the preoperative patients than in the normalweight population, and clearly warrant clinical attention, the relevance for ’successful’ outcomes in LAGB is unclear. Postoperative depression and its complications are also difficult to predict. PII: S1550-7289(07)00347-4 P105.
IS IT COST-EFFECTIVE TO SCREEN FOR HELICOBACTER PYLORI INFECTION IN BARIATRIC PATIENTS PRIOR TO GASTRIC BYPASS SURGERY? Tatiana Figueredo, MD; Stephanie F Yeager, RD; Christina Hartman; Peter N Benotti, MD, FACS; Anthony Petrick, MD, FACS; Mary Jane Reed, MD, FACS; William E Strodel III, MD, FACS; Christopher D Still, DO, FACN Geisinger Medical Center, Danville, PA Background: Gastrointestinal bleeding (GIB) following bariatric surgery is an uncommon occurrence, but not without potential morbidity, mortality and cost. The preoperative screening for Helicobacter pylori (H. pylori), a common link to GIB, remains controversial. We hypothesized that although the prevalence of H. pylori positive patients in the bariatric population remains low; the cost of screening prior to surgery significantly outweighs the potential risk and cost of GIB after gastric bypass surgery. Methods: A chart review of 443 (90 males; 353 females) patients undergoing gastric bypass patients was conducted. Each patient underwent stool antigen testing for detection of H. pylori infection prior to surgery. Prevalence was obtained in total bariatric population. Cost data was also collected from our system for both testing and hospitalization for GIB. Results: H. pylori were detected in 26 study patients (6%). Of the H. pylori positive patients 4.4% were male and 6.2% were female. The cost of stool H. pylori testing $25.00 per test or $11,075.00 for all study patients screened. The approximate cost for a patient to be
hospitalized for a GIB is $7,000.00. When comparing the cost of screening preoperatively with the cost of the hospitalization of one patient with a GIB, the benefits of screening prevail. Conclusion: Our preliminary data suggests that although prevalence of H. pylori in our bariatric surgery population is low, the costs of screening patients preoperatively significantly outweighs the potential morbidity, mortality and cost of not screening given the increased lifetime risk of GIB secondary to H. pylori infectivity. PII: S1550-7289(07)00348-6 P106.
MUSCULO-SKELETAL QUALITY OF LIFE: WHAT IS THE INTERACTION BETWEEN OBESITY, DEPRESSION, AND GI RELATED QUALITY OF LIFE? Elise Lawson, BS; Betsy Encarnacion, BS; Eric Ketchum, BS; John M Morton, MD, MPH Stanford School of Medicine, Stanford, CA Background: Two leading public health concerns in the US include morbid obesity and joint disease. Clearly, obesity affects musculoskeletal quality of life (MS Qol) but little is known about the interaction between obesity, depression and gastro-intestinal related quality of life (GIQoL.). The study aim was to determine the impact of obesity upon musculo-skeletal quality of life as well as determine the interaction between MS Qol, depression and GIQoL. Methods: The Short Form for Musculo-Skeletal Function Assessment (SMFA), Beck Depression Index (BDI), and Gastro-Intestinal Related Quality of Life (GIRQoL) surveys were administered prospectively for 86 gastric bypass patients. Patient demographics included average age 43, 82% female, and average pre-op BMI 49. Results: The morbidly obese patients had greatly reduced SMFA scores for every category and over-all total in comparison with US norms. The results are summarized in the table below. In addition, the SMFA was positively correlated with the BDI (Spearman coefficient, .47397, p value ⬍.0001) and negatively correlated with the GIRQoL, (Spearman coefficient,-0.57493, p value ⬍.0001). Conclusion: Morbid Obesity greatly affects MS QoL as measured by SMFA. In turn, there is great correlation between a new constellation of musculo-skeletal quality of life, depression, and GIrelated Quality of life. These interactions may be useful in predicting weight loss in future investigations as each may play a role in weight maintenance. PII: S1550-7289(07)00349-8 P107.
THE EFFECT OF PREOPERATIVE WEIGHT LOSS ON POSTOPERATIVE WEIGHT LOSS AND MAINTENANCE. Gregory A Broderick-Villa, MD; Jason Rasmussen, MD; Colleen Baucom-Pro, RD; Abigail Weston, BSN; Jennifer Campbell, RD; Judy Yamasaki, BSN; William D Fuller, MD; Mohamed R Ali, MD UC Davis, Sacramento, CA Background: Preoperative weight loss in the setting of Rouxen-Y gastric bypass (RYGB) remains incompletely studied and controversial. We hypothesize that preoperative weight loss is feasible, does not detract from expected weight loss after surgery, and may enhance overall weight loss and maintenance.
active H.pylori infection. The HpSA test represents a sensitive, noninvasive means of surveillance for active infection and response to treatment that is well suited for gastric bypass patients. PII: S1550-7289(07)00342-5 P101.
INSURANCE COVERAGE FOR BARIATRIC SURGERY: WHO GETS DENIED AND WHY? Vijaya L Nirujogi, MD; Ballem Naveen, MD; Silas Chikunguwo, MD; Bipan Chand, MD; Philip Schauer, MD Cleveland Clinic, Cleveland, OH Background: The aim of this study is to illustrate the frequency and reasons for insurance denials and ultimately aid the patient and physician navigate through the appeal process . Methods: This is a retrospective analysis of all patients evaluated at our institution for weight loss surgery from January 2005 to June 2006 that met the NIH criteria for surgery. All patients were evaluated by the bariatric team and fulfilled the criteria for surgery. Data was collected for variables including age, sex, BMI, comorbidities, Insurance carrier and the reason for denial. Results: Results: 615 patients who met the criteria for weight loss surgery were submitted for pre approval and 120 were denied (19.5%).Of these 94(78.3%) were women, 26(21.7%) were men, mean age was 44yrs, mean BMI⫽51 (range⫽35-89) kg/m2, mean number of. comorbidities ⫽ 3 (range⫽0-9). There were 2 deaths among the 120 patients waiting the appeal process, a mortality rate of 1.7%. Twenty one (17.5%) patients appealed the denials and of these 12( 57%) were ultimately approved . Conclusion: We found that the insurance companies cited lack of adequate documentation of supervised diet as the primary cause of denial. Contrary to this we noted extensive documentation to multiple failed diets. There were 2 deaths among the 120 patients waiting the appeal process, a mortality rate of 1.7%, almost double the national average of mortality rate for Roux-En-Y gastric bypass. Almost 20% of the eligible patients were denied access to surgery for reasons that have no proven benefit on patient selection or the outcome of surgery. PII: S1550-7289(07)00344-9 P102.
BARIATRIC SURGERY. . .WHY NOT? Joanne Rogers, CNS; Stephanie F Yeager, RD; Diane Daddario, RN; Christina Hartman; John Gerdes, PhD; Peter N Benotti, MD, FACS; Anthony Petrick, MD, FACS; William E Strodel, III, MD, FACS; Christopher D Still, DO, FACN Geisinger Medical Center, Danville, PA Background: Many qualified patients interested in bariatric surgery will not complete requirements needed to have surgery or ultimately decide not to have surgery. Current literature points to psychiatric issues, especially depression, as the major reason for drop-out in these types of programs. With the health risk of staying at a morbid obese state usually higher than those risks of surgery, we investigated reasons why patients who started our 6 month pre-surgical education program did not have their surgeries 1 year after starting. Methods: Twenty-eight patients of 61 total new patients were placed in the pre-surgery program, 3 of these patients had surgery within 1
333
year of the initial visit. The remaining 25 patients (18 females; 7 males) were interviewed by telephone. The question asked was “What factors contributed to why you initiated a program for bariatric surgery but did not continue treatment?” Total responses were collected; a respondent could have multiple answers. Results: Summary of responses: insurance issues-8 (32%); concern of surgical risk-6 (24%); fear of lifetime change-4 (16%); other medical conditions-3; life issues-3; reason unknown-3; distance-2 (8%); depression-2; unable to pay the program fee 1; work-1; prison-1; felt lost in the system-1; surgery elseware-1. Conclusion: These results suggest that insurance issues, concerns of surgical risk and fear of lifetime change are major barriers for patients undergoing bariatric surgery in our population and not psychiatric illness or depression as the current literature suggests. We may need to change the method of education to increase completion of the program. PII: S1550-7289(07)00345-0 P103.
THE ACCURACY OF SELF REPORTED WEIGHT AND HEIGHT IN THE BARIATRIC SURGERY PATIENT. Lauren Guenther, RD; Linda Bailoey, PA-C; Coleen Curley, RD; Ramsey M Dallal, MD, FACS Albert Einstein Heathcare Network, Philadelphia, PA Background: BMI is a critical value in the evaluation of patients for bariatric surgery. We examined the accuracy of patient reported height and weight in patients presenting for bariatric surgery. Methods: Patient weight and height were measured in our office and compared to weight and height that was self-reported on pre-registration materials. Results: 110 patients that were candidates for bariatric surgery were examined. Thirty-seven people (36%) were incorrect by an inch or more. Patients were equally likely to underestimate as overestimate their height. Average deviation from measured height was 0.03⫾0.96 inches. Patients either under- or overestimated their weight by an average of 2.2⫾2.4%. Fifty-eight patients (53%) deviated more than five pounds from their actual weight. Increasing weight predicted increased inaccuracy of self reported weight as a percentage of actual weight. Those patients ⬍ 300 pounds were inaccurate by 1.6⫾0.01%, those patients ⬎ 300 pounds were inaccurate by 3.1⫾0.3%, p⬍0.05. Patients were 1.7 times as likely to underestimate their weight than overestimate it. On average, reported and actual BMI were not statistically different. In four patients (3.6%) the BMI was affected by more than 5 points. BMI was accurate to 0.045⫾2.5 points comparing actual and reported values. Conclusion: Patients under-evaluation for bariatric surgery were surprisingly accurate with reporting their weight and height. Deviations in reported and actual BMI were clinically insignificant. PII: S1550-7289(07)00346-2 P104.
SUICIDE RISK IN LAGB PATIENTS. Eric H Prensky, PhD; Margaret Primeau, PhD; Mara Stankiewicz; Vafa Shayani, MD Loyola University Medical Center, Maywood, IL Background: Depression is common among morbidly obese patients according to both epidemiologic studies and the bariatric
334
Abstracts: 2007 Poster Session / Surgery for Obesity and Related Diseases 3 (2007) 299 –344
surgical literature. This comorbidity is not simple, though: symptoms of depression may improve, fail to change, or actually worsen following successful weight-loss surgery (e.g., Ryden et al., 1989; Waters et al., 1991; Dixon et al., 2003). We were prompted to investigate the prevalence of depression and suicidal ideation among our bariatric surgical patients when one was emergently admitted for intentional medication overdose 23 months after laparoscopic adjustable gastric banding (LAGB). Prior to surgery, this patient had denied acute depression. At 23 months, the patient had lost 51% of excess weight (%EWL). Methods: Preoperative data from psychological evaluations of 92 consecutive LAGB patients were tabulated. Frequencies represent patient responses to standard interview probes. Partial correlations were calculated for preoperative depression scores (MMPI-D)and later %EWL in 62 patients with at least six months follow-up. Results: A history of depression (53%) and current depression (28.4%) were common preoperatively. In addition, 14% acknowledged past suicidal ideation, and 3.5% reported a past suicide attempt. One patient disclosed current suicidal ideation, and 14% indicated a family history of a suicide attempt. Eventual weight loss was negatively but modestly correlated with elevations in preoperative depression (r⫽-.28, p⬍ .05). Conclusion: While histories of depression and suicidal ideation are far more common in the preoperative patients than in the normalweight population, and clearly warrant clinical attention, the relevance for ’successful’ outcomes in LAGB is unclear. Postoperative depression and its complications are also difficult to predict. PII: S1550-7289(07)00347-4 P105.
IS IT COST-EFFECTIVE TO SCREEN FOR HELICOBACTER PYLORI INFECTION IN BARIATRIC PATIENTS PRIOR TO GASTRIC BYPASS SURGERY? Tatiana Figueredo, MD; Stephanie F Yeager, RD; Christina Hartman; Peter N Benotti, MD, FACS; Anthony Petrick, MD, FACS; Mary Jane Reed, MD, FACS; William E Strodel III, MD, FACS; Christopher D Still, DO, FACN Geisinger Medical Center, Danville, PA Background: Gastrointestinal bleeding (GIB) following bariatric surgery is an uncommon occurrence, but not without potential morbidity, mortality and cost. The preoperative screening for Helicobacter pylori (H. pylori), a common link to GIB, remains controversial. We hypothesized that although the prevalence of H. pylori positive patients in the bariatric population remains low; the cost of screening prior to surgery significantly outweighs the potential risk and cost of GIB after gastric bypass surgery. Methods: A chart review of 443 (90 males; 353 females) patients undergoing gastric bypass patients was conducted. Each patient underwent stool antigen testing for detection of H. pylori infection prior to surgery. Prevalence was obtained in total bariatric population. Cost data was also collected from our system for both testing and hospitalization for GIB. Results: H. pylori were detected in 26 study patients (6%). Of the H. pylori positive patients 4.4% were male and 6.2% were female. The cost of stool H. pylori testing $25.00 per test or $11,075.00 for all study patients screened. The approximate cost for a patient to be
hospitalized for a GIB is $7,000.00. When comparing the cost of screening preoperatively with the cost of the hospitalization of one patient with a GIB, the benefits of screening prevail. Conclusion: Our preliminary data suggests that although prevalence of H. pylori in our bariatric surgery population is low, the costs of screening patients preoperatively significantly outweighs the potential morbidity, mortality and cost of not screening given the increased lifetime risk of GIB secondary to H. pylori infectivity. PII: S1550-7289(07)00348-6 P106.
MUSCULO-SKELETAL QUALITY OF LIFE: WHAT IS THE INTERACTION BETWEEN OBESITY, DEPRESSION, AND GI RELATED QUALITY OF LIFE? Elise Lawson, BS; Betsy Encarnacion, BS; Eric Ketchum, BS; John M Morton, MD, MPH Stanford School of Medicine, Stanford, CA Background: Two leading public health concerns in the US include morbid obesity and joint disease. Clearly, obesity affects musculoskeletal quality of life (MS Qol) but little is known about the interaction between obesity, depression and gastro-intestinal related quality of life (GIQoL.). The study aim was to determine the impact of obesity upon musculo-skeletal quality of life as well as determine the interaction between MS Qol, depression and GIQoL. Methods: The Short Form for Musculo-Skeletal Function Assessment (SMFA), Beck Depression Index (BDI), and Gastro-Intestinal Related Quality of Life (GIRQoL) surveys were administered prospectively for 86 gastric bypass patients. Patient demographics included average age 43, 82% female, and average pre-op BMI 49. Results: The morbidly obese patients had greatly reduced SMFA scores for every category and over-all total in comparison with US norms. The results are summarized in the table below. In addition, the SMFA was positively correlated with the BDI (Spearman coefficient, .47397, p value ⬍.0001) and negatively correlated with the GIRQoL, (Spearman coefficient,-0.57493, p value ⬍.0001). Conclusion: Morbid Obesity greatly affects MS QoL as measured by SMFA. In turn, there is great correlation between a new constellation of musculo-skeletal quality of life, depression, and GIrelated Quality of life. These interactions may be useful in predicting weight loss in future investigations as each may play a role in weight maintenance. PII: S1550-7289(07)00349-8 P107.
THE EFFECT OF PREOPERATIVE WEIGHT LOSS ON POSTOPERATIVE WEIGHT LOSS AND MAINTENANCE. Gregory A Broderick-Villa, MD; Jason Rasmussen, MD; Colleen Baucom-Pro, RD; Abigail Weston, BSN; Jennifer Campbell, RD; Judy Yamasaki, BSN; William D Fuller, MD; Mohamed R Ali, MD UC Davis, Sacramento, CA Background: Preoperative weight loss in the setting of Rouxen-Y gastric bypass (RYGB) remains incompletely studied and controversial. We hypothesize that preoperative weight loss is feasible, does not detract from expected weight loss after surgery, and may enhance overall weight loss and maintenance.